Appointment Request Form  
Thank you for your interest in Round Rock Counseling Services.  If you are interested in scheduling an appointment with one of our counselors we kindly ask that you please take a few moments to complete and submit this form.  Once submitted, our office manager Laurie, will reach out to discuss scheduling options with you.   Please allow 24  hours for a response.  We look forward to working with you.  
Email *
Clients full legal name: *
Clients Date of Birth: (MM/DD/YYYY) *
Parent/Guardian Name if client is a minor
Phone Number: (###-###-####) *
Email:  *
How will you pay for your sessions?  *
Required
If using insurance, please select from the following:
Do you prefer in-person or telehealth sessions? *
What is your availability? *
Please provide the days and times that work best for you (please be specifc) 
Preferred frequency of sessions? *
Type of therapy? *
Preferred counselor? *
Please provide a description of what brings you to seek therapy at this time.  This can be brief or as detailed as you'd like:  *
Preferred method of contact? *
Required
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